TRT without the use of Aromatase Inhibitors

[Dr. John Crisler]

As an Osteopathic physician, less drugs is better. To be clear, I wish we never had to add an AI to a gentleman's TRT regimen.

Through this thread, let's explore this topic. I am especially interested in hearing from guys who previously were on an AI, then successfully discontinued it.

At a given weekly testosterone dosage, we can often times reduce estrogen and/or elevated estrogen symptoms, by dividing up the individual dosages. Rapid accelerations in serum androgen levels increase the activity of the aromatase enzyme. So smoothing out the dosing lowers subsequent estrogen.

This has the added benefit of retaining more testosterone in the body; rapid accelerations in androgen levels also increase urinary excretion of androgens (but not estrogen, unfortunately). One study concluded 40mg twice per week of test cyp is about the same as 100mg once per week.

Many are finding relief from injecting small daily doses. I am happy to have all my injectable TRT guys do that..IF they have the time. Everything is a negotiation in medicine.

Also, just changing hormone levels can cause effects, both positive and negative, and while a hormone level is both rising or falling. For that reason, I usually have my patients wait a month before doing labs, to let things even out.

From what I have read, some are reporting things got better, but not until the second month. Getting a guy to wait it out is the hard part. Many get quite anxious if they feel even a slight bit of nipple sensitivity.

And there is always the chance to reduce the testosterone dose. But if you have started low/gone slow, you have already been at the lower dose. This strategy works only when a patient presents on a dose of TRT which is too high for them. As we always say, "more is not better", and "every-body is different".

 

[Fernando Almaguer]

Hello Dr. John,

I really enjoy reading your well written posts. To begin, I am wondering if small more recent doses of Test cypionate would raise bad cholesterol or change lipid panels more so than injecting less frequently. I have had great numbers so far but my last labs, bad numbers are creeping up (still within normal range). Also, to address your post, I have tapered AI dosing a lot and am finding that these smaller, more frequent doses (daily 20mg) keep e2 at 20-25 pg/dl range. Thanks ahead for your response. Hope I'm worrying for nothing.

 

[Raaj]

As an Osteopathic physician, less drugs is better. To be clear, I wish we never had to add an AI to a gentleman's TRT regimen.

Through this thread, let's explore this topic. I am especially interested in hearing from guys who previously were on an AI, then successfully discontinued it.

At a given weekly testosterone dosage, we can often times reduce estrogen and/or elevated estrogen symptoms, by dividing up the individual dosages. Rapid accelerations in serum androgen levels increase the activity of the aromatase enzyme. So smoothing out the dosing lowers subsequent estrogen.

This has the added benefit of retaining more testosterone in the body; rapid accelerations in androgen levels also increase urinary excretion of androgens (but not estrogen, unfortunately). One study concluded 40mg twice per week of test cyp is about the same as 100mg once per week.

Many are finding relief from injecting small daily doses. I am happy to have all my injectable TRT guys do that..IF they have the time. Everything is a negotiation in medicine.

Also, just changing hormone levels can cause effects, both positive and negative, and while a hormone level is both rising or falling. For that reason, I usually have my patients wait a month before doing labs, to let things even out.

From what I have read, some are reporting things got better, but not until the second month. Getting a guy to wait it out is the hard part. Many get quite anxious if they feel even a slight bit of nipple sensitivity.

And there is always the chance to reduce the testosterone dose. But if you have started low/gone slow, you have already been at the lower dose. This strategy works only when a patient presents on a dose of TRT which is too high for them. As we always say, "more is not better", and "every-body is different".

Hi,
I would like to start TRT in next few weeks
My current TT is 378 and shbg is 50
I do not want to take any medicines apart from multivitamins in future or till my lifetime if at all no need is risen and for sure not in my current age of 40
What should be my starting TRT dosage and frequency as I am already estrogen dominant and do not want to mess up with my estrogen anymore. I just hate AI and do not want to use in my life anymore. I am even happy with a healthier level if not superman level
Thanks

 

[Sean Mosher]

Honestly, when I first started TRT I believe I probably needed the Anastrozole.
The dose I was given was fairly high at the time and I did well IMO on that protocol.
I've switched to EOD injections and so far haven't had any problems with estrogen as far as I can tell.
I've dropped the Anastrozole completely and have just been monitoring labs and paying attention to how my body reacts.
So far so good.

 

[Nashtide]

I inject 60mg of T cyp E3.5D and 250iu of hcg twice weekly. I went 2 months without an AI and when I ran labs my E2 was in the high 40’s. The only things I noticed was my sleep wasn’t as good and my libido was down a bit. I started adding a very tiny dose of anastrazole (0.1mg) at the time of my T injections and within a week my sleep and libido improved. So, I’m okay with this small dose of anastrazole.

 

[Raaj]

I think the purpose of using any Hrt is not to use any drugs apart from TestosteronE.
I would be happy to stay at optimal level without using any drugs as we can see young guys do not use any drugs apart from food and still have a healthy hormones. Once we introduce any outside drugs in our body it will hamper the natural process of body. Everyone is different.
They key for me is to protect liver and all natural processes as long as I can
Once we introduce any outside drug specially AI things can change dramatically.
Urologists and endocrinologist in India seems to be treating the disease states and not root cause.
I sewn 11endos and now finally last endo prescribed me TRT. And told me manage your dose and sides but be aware not to use any additional drugs even no HCG and AI till you feel that it is needed

 

[YBWV]

I'm a guy who loves his E2 - it's neuroprotective, maintains my bone and muscle mass, helps makes me an amazing lover and even assists me in completing the Times of London crossword each day.
I don't want anyone or anything inhibiting my aromatase.
So no use of AIs on my part.

I believe the move towards designing TRT protocols that don't involve the use of AIs will be a significant step in the progress of men's hormonal health and I welcome the opportunity to join the discussion so my thanks to Dr Crisler for starting it.

A lot of progress has been made in recent years in TRT and continues to be made however, in my opinion, that progress may have have been confounded by the fact that many of the early practioners and participants come from a bodybuilding background where the use of higher amounts of exogenous T and the control of the concomitant rise in E2 with an AI is standard practice.

If patients in actual TRT require/need anabolism and protein-synthesis from their therapy then sure higher amounts of T will be required and an AI may be needed. However there appear to be many instances where guys present with the typical hypo symptoms (wanting help with sexual function, mood and drive) and are prescribed protocols that send their E2 way high and they then "need" an AI to balance their hormones. Why create the imbalance in the first place?

If the higher amounts of exogenous T are prescribed to attain sufficient levels of androgens (crucially DHT) could it be better to balance the 2 metabolites (DHT:E2) by using a lesser, but adequate, amount of exogenous T together with DHT (by way of Proviron, Andractim or T Cream to the scrotum), thereby avoiding the use of an AI ?

 

[Vince Carter]

@Dr. John Crisler

I require an AI even with 16mg/D Cyp. I aromatase at a crazy rate. I eliminated one at a time, Pregnenolone, then DHEA, then HCG, I got to use Cyp only was still very high (88) LC/MS/MS with profound negative symptoms...hot/sweaty in bed, aggressive/volatile/low tolerance for people, body acne was out of control, sexual dysfunction. I too slowly reduced my daily Cyp from 25mg in 2mg increments...never got E and its problems to resolve.
Through it all I had to use .25mg Anastrozole EOD and that still wasn't enough, I was still pushing the lab range on Free E (>0.45).
I've improved with switching to Aromasin, I'm doing the best I've been on TRT with 12.5mg EOD and my LC/MS/MS in the single digits.
At that point my body acne has largely resolved, I no longer have to take 2 showers a day and scrub my body with a brush. A lot of the body heat has come down to a tolerable point, orgasm is greatly improved and I have improved penile sensitivity. Still require PDE5i though which is the only thing I would complain about at this time.

I know you understand my SHBG @ 12 and how the Free E is so very problematic but I think I've figured it out for me...LC/MS/MS needs to be at or below the SHBG value. It was one of your remarks of having low SHBG that could tolerate almost no Estrogen that inspired me to go down this path.

Honestly I have zero negative/low E symptoms using 12.5mg of Aromasin, Daily.

 

[Gman86]

@Dr. John Crisler

I require an AI even with 16mg/D Cyp. I aromatase at a crazy rate. I eliminated one at a time, Pregnenolone, then DHEA, then HCG, I got to use Cyp only was still very high (88) LC/MS/MS with profound negative symptoms...hot/sweaty in bed, aggressive/volatile/low tolerance for people, body acne was out of control, sexual dysfunction. I too slowly reduced my daily Cyp from 25mg in 2mg increments...never got E and its problems to resolve.
Through it all I had to use .25mg Anastrozole EOD and that still wasn't enough, I was still pushing the lab range on Free E (>0.45).
I've improved with switching to Aromasin, I'm doing the best I've been on TRT with 12.5mg EOD and my LC/MS/MS in the single digits.
At that point my body acne has largely resolved, I no longer have to take 2 showers a day and scrub my body with a brush. A lot of the body heat has come down to a tolerable point, orgasm is greatly improved and I have improved penile sensitivity. Still require PDE5i though which is the only thing I would complain about at this time.

I know you understand my SHBG @ 12 and how the Free E is so very problematic but I think I've figured it out for me...LC/MS/MS needs to be at or below the SHBG value. It was one of your remarks of having low SHBG that could tolerate almost no Estrogen that inspired me to go down this path.

Honestly I have zero negative/low E symptoms using 12.5mg of Aromasin, Daily.

Do you happen to know your free E2 level? Or have you tried using a free E2 calculator? I’m very curious to where your free E2 is.

 

[Deleted member 16042]

A very long story how I got there, but most recently, after trying to stick out dosage reduction for E2 to reduce/stabilize I was still going crazy with mood swings and bloating with E2 in the mid 30's.

Now on: 0.0625mg anastrozole, T cyp 24mg, HCG 280 iu, all EOD.

Labs on this kind of regimen: Total T in the 900-1000 range, Free T 18-21, E2 LC/MS/MS 25-30, SHBG 52.

 

[Gman86]

A very long story how I got there, but most recently, after trying to stick out dosage reduction for E2 to reduce/stabilize I was still going crazy with mood swings and bloating with E2 in the mid 30's.

Now on: 0.0625mg anastrozole, T cyp 24mg, HCG 280 iu, all EOD.

Labs on this kind of regimen: Total T in the 900-1000 range, Free T 18-21, E2 LC/MS/MS 25-30, SHBG 52.

How are you feeling now that your E2 is a little lower?

 

[Deleted member 16042]

How are you feeling now that your E2 is a little lower?

Yep, That's the point. Mood swings gone, bloating gone. Much more stable.

 

[HealthMan]

After i lowered my testosterone dosage to 100-110mg a week my estradiol has been inside the labcorp range (low 30s). However i am prone to nipple issues so i use 0.125mg anastrozole twice a week and that lowers my estradiol to 20-25 and i feel great without nipple issues. My TT is in the highs 700 and FT low mid 20s

 

[Gman86]

Yep, That's the point. Mood swings gone, bloating gone. Much more stable.

That’s awesome to hear. It’s crazy how different we all are. With your SHBG being 52, would of thought for sure that having your E2 in the 30’s would cause zero high E2 side effects. Thanks for posting this, really drives home that we all have to find our individual range(s) for each hormone, especially E2 it seems. Vince Carter’s story definitely drives this fact home as well.

 

[Gman86]

After i lowered my testosterone dosage to 100-110mg a week my estradiol has been inside the labcorp range (low 30s). However i am prone to nipple issues so i use 0.125mg anastrozole twice a week and that lowers my estradiol to 20-25 and i feel great without nipple issues. My TT is in the highs 700 and FT low mid 20s

What’s your SHBG at? Glad to hear you’re feeling great on your current protocol. Looks like there’s a common theme with guys having success with micro dosing their ai. Just goes to show that maybe it’s the doses, and not the actual ai, that is causing the issues for a lot of men on TRT after all.

 

[HealthMan]

What’s your SHBG at? Glad to hear you’re feeling great on your current protocol. Looks like there’s a common theme with guys having success with micro dosing their ai. Just goes to show that maybe it’s the doses, and not the actual ai, that is causing the issues for a lot of men on TRT after all.

My SHBG hoovers around 22-24. I am a firm believer in lower dosages.

 

[tropicaldaze1950]

This link is from the site of Dr. Henry Lindner, an interventional endocrinolosgist in Pennsylvania. Near the end of the page on testosterone is a link to a page on estradiol/estrogen, in which he posted clinical studies that refute the position of managing E2 in men on TRT. Now, IMO, even if your thyroid panel looks normal, perhaps one still should be taking desiccated or t3/t4 to improve metabolic function in order to keep E2 in range. When we're young and all hormones are in natural balance, our bodies don't need external intervention. The other issue which my primary is seeking an answer to is the possibility of hypopituitary function. Hypopit, from my understanding, is treated by supplementing the hormones that are low, such as thyroid and testosterone. Testosterone

 

[JimBob]

This link is from the site of Dr. Henry Lindner, an interventional endocrinolosgist in Pennsylvania. Near the end of the page on testosterone is a link to a page on estradiol/estrogen, in which he posted clinical studies that refute the position of managing E2 in men on TRT. Now, IMO, even if your thyroid panel looks normal, perhaps one still should be taking desiccated or t3/t4 to improve metabolic function in order to keep E2 in range. When we're young and all hormones are in natural balance, our bodies don't need external intervention. The other issue which my primary is seeking an answer to is the possibility of hypopituitary function. Hypopit, from my understanding, is treated by supplementing the hormones that are low, such as thyroid and testosterone. Testosterone

Thanks for the link.

 

[MidwestNomad]

I just started TRT with Defy and I’m on my third injection. I am due for follow-up labs in 3 months, however, I am not taking my AI yet. I was prescribed .125 of Ameridex to be taken e3.5d or as needed when sides arise. My fear is crashed estrogen.

I am going to wait until 6 weeks to get my own blood panel drawn to see where my E2 levels are at.

I hear mixed opinions on waiting to “feel it”, but I’ve had my E2 levels at 10.0 before and don’t ever want to feel that again.

 

[rafapark]

As an Osteopathic physician, less drugs is better. To be clear, I wish we never had to add an AI to a gentleman's TRT regimen.

Through this thread, let's explore this topic. I am especially interested in hearing from guys who previously were on an AI, then successfully discontinued it.

At a given weekly testosterone dosage, we can often times reduce estrogen and/or elevated estrogen symptoms, by dividing up the individual dosages. Rapid accelerations in serum androgen levels increase the activity of the aromatase enzyme. So smoothing out the dosing lowers subsequent estrogen.

This has the added benefit of retaining more testosterone in the body; rapid accelerations in androgen levels also increase urinary excretion of androgens (but not estrogen, unfortunately). One study concluded 40mg twice per week of test cyp is about the same as 100mg once per week.

Many are finding relief from injecting small daily doses. I am happy to have all my injectable TRT guys do that..IF they have the time. Everything is a negotiation in medicine.

Also, just changing hormone levels can cause effects, both positive and negative, and while a hormone level is both rising or falling. For that reason, I usually have my patients wait a month before doing labs, to let things even out.

From what I have read, some are reporting things got better, but not until the second month. Getting a guy to wait it out is the hard part. Many get quite anxious if they feel even a slight bit of nipple sensitivity.

And there is always the chance to reduce the testosterone dose. But if you have started low/gone slow, you have already been at the lower dose. This strategy works only when a patient presents on a dose of TRT which is too high for them. As we always say, "more is not better", and "every-body is different".

Dr Crisler, do you recommend more frequent injections regardless of the SHBG? In my case I am injecting

As an Osteopathic physician, less drugs is better. To be clear, I wish we never had to add an AI to a gentleman's TRT regimen.

Through this thread, let's explore this topic. I am especially interested in hearing from guys who previously were on an AI, then successfully discontinued it.

At a given weekly testosterone dosage, we can often times reduce estrogen and/or elevated estrogen symptoms, by dividing up the individual dosages. Rapid accelerations in serum androgen levels increase the activity of the aromatase enzyme. So smoothing out the dosing lowers subsequent estrogen.

This has the added benefit of retaining more testosterone in the body; rapid accelerations in androgen levels also increase urinary excretion of androgens (but not estrogen, unfortunately). One study concluded 40mg twice per week of test cyp is about the same as 100mg once per week.

Many are finding relief from injecting small daily doses. I am happy to have all my injectable TRT guys do that..IF they have the time. Everything is a negotiation in medicine.

Also, just changing hormone levels can cause effects, both positive and negative, and while a hormone level is both rising or falling. For that reason, I usually have my patients wait a month before doing labs, to let things even out.

From what I have read, some are reporting things got better, but not until the second month. Getting a guy to wait it out is the hard part. Many get quite anxious if they feel even a slight bit of nipple sensitivity.

And there is always the chance to reduce the testosterone dose. But if you have started low/gone slow, you have already been at the lower dose. This strategy works only when a patient presents on a dose of TRT which is too high for them. As we always say, "more is not better", and "every-body is different".

Dr Crisler if I understand correctly you recommend increasing dosing frequency as a way to control elevated estrogen symptoms. Would this apply for guys with high SHBG too? My SHBG is 53 and my E2 sensitive is 39 pg/ml. I would like to start using DHEA as mine is low ( 117.5 ug/dl) but last time I tried dosing 25 mg DHEA daily by Estradiol increased significantly. Would increasing dosing frequency to say 3 times a week help control my E2? Should I go to daily injections then? I really don't mind injecting more often and I prefer that to increasing my AI. Thanks!